Kids Central - Central Church of God

CENTRAL CHURCH KIDS CAMP
MEDICAL RELEASE
I hereby give my full and unconditional permission except as noted below, to the staff and named workers of
Central Church to administer over-the-counter medicine to my child if they deem it necessary and appropriate.
These medicines would include, but not be limited to the following:
Aspirin
Tylenol
Advil
Pepto Bismol
Immodium AD
antacids such as Tums, Rolaids, etc.
cold medicine
Kids
CampAugust
July 16-19,
Kids Camp
1 – 4, 2016
2015
This permission is extended to Tony Arnett, Melinda Arnett, and Paula Byrd
Student’s Full Name: __________________________________________________________
EXCEPTION TO THE ABOVE: I do not give my permission for the following to be administered at any time or
under any circumstances.
Summer Camp
Kids Central
July 16-19
2016
Current 1st – 4th graders
at Nosoca Pines Ranch in Liberty Hill, SC
List (please be specific): ______________________________________________________________________
__________________________________________________________________________________________
My child takes the following prescription medications on a regular basis (list): ____________________________
__________________________________________________________________________________________
Known allergies (food or medication), please be specific: ____________________________________________
__________________________________________________________________________________________
PARENTAL APPROVAL This form must be signed by both parents or the child’s legal guardian. In the case the
parents are legally divorced or separated, the parent who has been given legal custody must sign. Each student
must have his/her own separate form.
Signed
Father: ____________________________________________
Date: ________________________________
Mother: ____________________________________________
Date: ________________________________
Legal Guardian: _____________________________________
Date: ________________________________
Central Church Summer Camp 2015
5301 Sardis Rd. Charlotte, NC 28270
www.centralnc.org • 704.364.5003
Kids
July 16-19,
KIDS Camp
CAMP August
1 – 4,2016
2015
cost is $240
In consideration for being accepted by Central Church for participation in the in Nosoca Pines Ranch, Liberty Hill, SC,
we/I, being 18 years of age or older, do for ourselves (myself) [and for and on behalf of my student if said student is not 18
years of age or older] do hereby release, forever discharge and agree to hold harmless Central Church and the directors
thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage
and expenses, of any nature whatsoever which may be incurred by the undersigned and the student-participant that occur
while said student is participating in the above described trip or activities involved therein.
(Including $25 nonrefundable deposit)
All payments must be paid by June 26, 2016.
Financial Aid
Furthermore, we/I [and on behalf of our (my) student-participant if under the age of 18 years] hereby assume all risk of
personal injury, sickness, death damage and expense as a result of participation in recreation and work activities involved
therein.
Financial assistance is available for fund-raiser participants. A fund-raiser
participant is one who sells at least one box of the World’s Finest Chocolates,
which are available in the Kids Central building. You can contact Melinda
Arnett with any additional questions regarding fund-raising.
Further authorization and permission is hereby given to said church to furnish any necessary transportation, food, and
lodging for this student.
The deadline for financial aid application is June 5, 2016. Forms turned in after
the deadline may not be processed.
The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents,
for any liability sustained by said church as the result of the negligent, willful or intentional acts of said student, including
expenses incurred attendant thereto.
Cancellation
No refunds will be given after June 26, 2016.
If the student has not attained the age of 18 years:
We/I are the parent(s) or legal guardian(s) of this student, and hereby grant our/my permission for him/her to participate
fully in said trip, and hereby give our/my permission to take said student to a doctor or hospital and hereby authorize
medical treatment, including but not limited to emergency surgery or medical treatment, and assume the responsibility of
all medical bills, if any.
Registration
PLEASE
Please include your $25
nonrefundable registration
fee with this form (due by
Sunday, June 5).
For further information,
call 704.295.6890 or email
[email protected].
Mail payments to
Central Church
Attn: Camp
5301 Sardis Rd
Charlotte, NC 28270
Liability
Liability Release
Release Form
Form 2016
2015
PRINT
Further, should it be necessary for the student to return home due to medical reasons, disciplinary action or otherwise,
we/I hereby assume all transportation costs.
C H I L D
LAST NAME
FIRST NAME
Type or Print Name of Student
SEX: M
F
(
)
Parent(s) Telephone #
DOB:
/
/
CURRENT GRADE LEVEL
AGE (AT CAMP):
(2015/2016) : 1
2
3
4
Only student need sign if 18 years of age or older. If under 18,
parent(s) must sign.
(
)
Parent(s) Work #
Mother
Date
(
)
Parent(s) Cell #
Father
Date
Legal Guardian
Date
Insurance Company (insurance required)
ADDRESS
Emergency Name & Phone Numbers:
CITY/STATE/ZIP
PA R E N T
(
S
Policy #
)/
G U A R D I A N
(
S
)
Family Physician
NAME
(
)
Physician’s Telephone #
HOME PHONE
EMAIL ADDRESS
Responsible party’s home address:
MOM CELL (OR GUARDIAN)
Responsible party’s company name:
DAD CELL (OR GUARDIAN)
ADDRESS (IF DIFFERENT FROM ABOVE)
Phone #: (
)